What does maximum out of pocket expense for health insurance mean?

Question

My health insurance is that I pay 40% and the out of pocket maximum says $5,000.00

So if the hospital bill is $400,000.00 do I have to pay 40% of that, or do I only pay $5,000.00

Answer 1

once you have paid out of pocket the $5,000 that is all you will pay and health care will cover the rest... at least that's how mine is.

Answer 2

The numbers I am using are made up and are not intended to be the real insurance cost. Each policy will be different. If you are not an American, I apologize for talking in dollars instead of the currency of your country. The concept remains the same. Deductible is the amount you will pay each time you go to the doctor or to the hospital. It may be a set amount, like $15.00 or it may be a percentage of that days bill, say 20 percent. The maximum out of pocket expense limit is an amount the insurance will collect from you annually before they pick up 100 percent of your medical cost for the remainder of that year. This is usually a fixed dollar amount. If you go to the doctor or hospital frequently, your deductible may reach the maximum out of pocket expense quickly (say $2,000.00 for the year) and the insurance will pay all medical expenses after this, for the rest of the year. If you don't go to the doctor often, you may not reach the $2,000.00 limit for the year. Always ask lots of questions from the company you are considering.

Answer 3

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RE:
What does maximum out of pocket expense for health insurance mean?
My health insurance is that I pay 40% and the out of pocket maximum says $5,000.00

So if the hospital bill is $400,000.00 do I have to pay 40% of that, or do I only pay $5,000.00

Answer 4

If you have a PPO (Preferred Provider Organization) plan your maximum out of pocket is the most you would pay in a calendar year (January 01,- December 31), if you go within that "Preferred Network of providers". So Stay within your network of providers, if you don't you will pay "MUCH MORE". I would suggest you call your Health Insurance Agent, or Health Insurance Company to verify any coverage especially before any surgery. Even with PPO plans, Pre-Authorization is commonly needed, and even mandatory.

Answer 5

It means you pay 40% of the costs until that 40% gets to $5000 and then the insurance pays everything else.

Of a $400,000 bill, you'll only pay $5000, if that is your out of pocket maximum.

Answer 6

I know you have gotten a lot of various answers. Safety Dancer is the closest to correct. The $5000 maximum is supposed to be all you pay, but it may not be. The insurance company will only pay 100% of what they approve and they may not approve all your charges from either the doctor or hospital. It is very misleading when you get your bills and see that you owe more than $5000.

Answer 7

"Ain't no stopping us..." is correct, as far as your question goes.

But, there may be other stipulations, exceptions, and limitations in your health contract that you have not discovered that would make the answer different from her answer.

Typically, health plans are either "preferred provider" (PPO) or "health maintenance" (HMO). Looks like yours is a PPO and as such as different benefits and coverage depending on whether you stay within the network of medical providers (doctors, clinics, hospitals, etc.) or whether you go out of network. Be sure you know who is in and who is out of network.

Also, understand that some medical providers (ambulance services in particular) have disputes with insurance carriers over what is a "fair and reasonable" charge for services. In the event that a medical provider thinks that what they are getting is too little, they can charge you for the additional amount that they think is fair. I just got burned for an additional charge from such a provider. It's happening more and more. You can challenge it, but it's a royal hassle.

Hope that helps.

Answer 8

It means you pay 40% of all expenses until your cumulative out of pocket expenses (the 40%) is 5,000. After that, the insurance company pays for 100%.

In your example, you would pay 40% of the first 12,500. That would be $5,000. After that, the insurance company is responsible for the entirety of the rest. You would pay $5,000, not 40% of 400,000.

Answer 9

Seeing as how everybody has answered your question differently, and that I don't believe in insurance (EXTORTION!) I would recommend that you consult your insurance company as to the meaning of that, they should have a 800# for you to call!

Good luck!

Answer 10

you pay the $5000.00 but it depends if the Company counts your deductable before that say you may pay your doctors visits ( maybe $10.00 each visit ) and some add up all the 10.00 you pay for you out of pocket amount so you visit the doctor 3 times and than get in the hospital for $400,000 you may only owe 4970.00 for that visit. or you may owe the full $5000.00 and that is per year ( I am guessing it is per year). and anything your insurance does not cover does not count. ( it may only allow one set of x-rays so if you get 2 you may need to pay for the second set and it may not count towards your $5000.00